Enrique Baca. Crisis Económica y Suicidio

Dr. Enrique Baca García
CRISIS ECONÓMICA Y EL SUICIDIO
El suicidio en las circunstancias actuales

E. Baca-García
PUNTOS CLAVE
Why are some people healthy and others not?
It seems a simple question.
The answers, however, are complex and have to do
not only with disease and illness, but also with who
we are, where we live and work, and the social and
economic policies of our government, all of which
play a role in determining our health.
Institute of Medicine. The Future of the Public’s Health in the 21st Century, 2003
PARA EL CLÍNICO
• Integrar datos y metodologías diferentes
• Causas del Suicidio vs causa del suicidio en un
paciente
• Debate ideologizado

E. Baca-García
INDICE
Introducción
Epidemiología y Sociología
Suicidio en España
Clínica
Conclusion

E. Baca-García
 163.000 European deaths
2nd cause of death in 15-35 years old
Makes up 2,3% of all diseases

E. Baca-García
COSTE ECONOMICO DEL SUICIDIO
 USA 1990
• 30,906
• $5.07 billion (2005 dollars)
Irlanda 2001-2002 (1% PIB)
• 519-478
• € 906 millon 2001
• €835 millon 2002 ( 2001 €).
Suiza
• 15 000 - 25 000 intentos
• Costes directos 191 million CHF
Death Stud. 2007 Apr;31(4):351-61
Crisis. 2007;28(2):89-94.

E. Baca-García
ACTUALIDAD I
www.thelancet.com Published online March 27, 2013
http://dx.doi.org/10.1016/S0140-6736(13)60102-6

E. Baca-García
CRISIS ECONOMICA Y SALUD MENTAL
 Consecuancias de la crisis economica:
• Disminución de capacidad adquisitivas ( pobreza)
• Paro
• Disminucion presupsueto publico
 El despempleo afecta a al bienestar y autostima, se
relaciona con depresión, ansiedad, sintomas
psicosomaticos.
 Las personas desempleadas tienen un 34% de
problemas psicologicos frente al 16% de los
empleados.
 El efecto sobre la salus mental es mayor.
• Cuanto más largo es el desempleo
• En paises en desarollo , con inequidades
• Sistemas de protección socal escasos
Uutela A. Economic crisis and mental health. Current Opinion in Psychiatry 2010,
23:127–130

E. Baca-García
ACTUALIDAD II
http://wiki.15m.cc/wiki/Lista_de_suicidios_relacionados_con_desahucios

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ANTES DE VALORAR DATOS I
“fluctuation between 10.0 per 100,000
and 19.0 per 100,000 over the past 100
years.”
Nock MK et al. Suicide and Suicidal Behavior. Epidemiol Rev. 2008 ; 30(1): 133–154.
NATURAL FLUCTUATION 50%

E. Baca-García
ANTES DE VALORAR DATOS II
Errores en tasas por paises: infranotificación
Claassen CA. National Suicide Rates a Century after Durkheim: Do We Know
Enough to Estimate Error? Suicide and Life-Threatening Behavior 40(3) 2010

E. Baca-García
ANTES DE VALORAR DATOS III

E. Baca-García
ANTES DE VALORAR DATOS IV

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DURKHEIM
El suicidio (1897)
“El único medio de proceder metódicamente consiste en
clasificar, según sus propiedades esenciales, los suicidios
cometidos por los locos, constituyendo así el tipo principal de
los suicidios vesánicos e investigar después si todos los casos de
muerte voluntaria caben en estos cuadros nosológicos. En otros
términos, para saber si el suicidio es un acto especial de los
alienados, es preciso determinar las formas que afecta en la
enajenación mental y ver a continuación si estas son las únicas
que toma.
Los alienistas se han preocupado poco de clasificar los
suicidios de alienados”
“No existe ningún estado psicopático que sostenga con el
suicidio una relación regular e incontestable. Porque una
sociedad contenga más o menos neurópatas o alcohólicos no se
darán en ella más o menos suicidios”

E. Baca-García
DURKHEIM
Lester BY. Learning from Durkheim and beyond: The economy and suicide.
Suicide & Life - Threatening Behavior; 2001; 31 (1):15-31
“Singularmente hay dos factores del suicidio que tienen el uno con
el otro una afinidad especial, y son el egoísmo y la anomia”
• EGOISMO: falta de integración social (religión, educación, vida
familiar y política)
• ANOMIA: falta de regulación o control por la sociedad (cambios
económicos, desempleo, divorcio)
U Drurkheim
Contraciclica
Prociclica

E. Baca-García
SUICIDIO ECONOMIA
 Relación stress económico y suicidio: pobreza y
desempleo
 Hombres 15- 29 años más vulnerables
 Variables de confusión alcohol y depresión
 4 tipos de métodos
• Estudios trasversales individuales (3b):
Casos control - > hombres en UK,(Platt, 1984)
• Estudios agregados (2c):
Mortalidad poblacional - > Resultados controvertidos
• Estudios longitudinales (2b):
Cohortes -> Problemas laborales vs no 25 años RR 2.5 (Rorsman, 1980)
• Estudios agregados de tendencias temporales (2c):
Mortalidad poblacional periodo - >resultados contradictorios, indicios
en hombres jóvenes
Ademas series de casos (4)y opiniones de expertos (5)
Niveles de evidencia (1-5) según http://www.cebm.net/?o=1025
Stack S.Suicide: A 15-Year Review of the Sociological Literature - Part I: Cultural
and Economic Factors , Suicide and Life-Threatening Behavior, 2000; 30:2.145

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Autor, Pais Años Metodo Resultado
Thomas K, 2010 UK 1861-2007 Office for National Statistics (ONS)
age-standardized suicide rates (European Standard)
Suicide rates increased in all age groups in the 1930s, coinciding
with the Great Depression.
Kwon JW, 2009 Korea 1986-2005 Korean National Statistical Office (NSO)
age-standardized using the standard population
in 2005.
the Asian economic downturn in 1997
evoked an increase in suicide rates with a ripple effect
occurring even after economic recovery in Korea
Redanie, 2011 Philipines 1974-2005 PhilippineHealth Statistics (PHS) produced
Age-standardized rates were computed using the
WHO world standard population
The increasing rates of suicide and accidental deaths and
corresponding decrease in undetermined deaths are
suggestive of some underreporting and misclassification.
Andres AR, 2010 Denamark 1970-2006 Dynamic econometric model of suicides on the basis
of time series data
Rise in real per capita income and fertility rate decreases
suicides for males and females. Divorce is positively associated
with suicides and this effect seems to be stronger for men. A fall
in unemployment rates seems to lower significantly suicides
in males and females
Barr B, 2012 UK 2008-10 Time trend analysis comparing the actual number of
suicides with those that would be expected if
prerecession trends had continued.
Multivariate regression models quantified the
association between changes in unemployment
(based on claimant data) and suicides (based on data
from the National Clinical Health Outcomes
Database).
We estimated 846 more suicides among men (818 to 877) and
155 more suicides among women (121 to 189) than would have
been expected if these trends had continued in the period 2008-
10.
Kolves K, 2013 Eastern
European
countries
1990-2008 World
Health Organization (WHO)
In both models, unemployment (P < 0.05) was positively
associated with male mortality rates, while GDP per capita (P <
0.001 for suicide and P < 0.05 for suicide ⁄ UD), GPs per
100,000 (P < 0.05) and birth rates (P < 0.001) were negatively
associated with mortality rates. Both models 1a and 1b showed
that the 5-year indicator variables were associated with a
decrease in male mortality rates (using 1990–1994 as a
reference category).
Unemployment was positively associated with female suicide (P
< 0.05) and GDP per capita negatively associated with female
suicide (P < 0.001). However, they did not have an effect on the
suicide or UD rate. Alcohol consumption per capita was
negatively associated with the female suicide rate (P < 0.05).
SUICIDIO CRISIS

E. Baca-García
Statistically significant correlations between GDP (PPP) per
capita and rate of suicide per 100,000 (WHO)
Blasco-Fontecilla H. Worldwide impact of economic cycles on suicide trends over 3
decades: Differences according to level of development. BMJ Open 2012 (2 (3):000785

E. Baca-García
GDP and rate of suicide

E. Baca-García
EFECTOS DE CRISIS EN DISTINTOS PAISES
 Crisis económica asiática 1997-98
• Tailand ia fue el pais más afectado por la crisi y la tasa de
suicidio aumento en 199 y cayó despues de la crisis (5.9 in 1977,
8.6 in 1999 and 7.8 in 2002)
• Japón, Hong Kong y Koreaa tubieron un exceso de 10,400
suicidios (8800–11,300) en 1998 . Afectando más a hombres en
edad activa
• La crisi no afectos a las tendencias en Taiwan and Singapore
donde la crisis afecto menos a GDP y desempleo.
 Rusia:
• Aumento en 1998 y descenso despues
 Finlandia
• Aumento desmpleo durante la crisi de 1990 no tuvo efecto sobre
la tasa de suicidio
BMC Public Health 2009, 9:72. doi:10.1186/1471-2458-9-72
Social Science & Medicine 68 (2009) 1322–1331

E. Baca-García
SUICIDIO CRISIS
 26 EU paises entre 1970 and 2007 ( 550 años pais)
 Efectos a corto plazo (3 años)
  de 1% de la tasa de desempleo supone:
 de a 0.79% suicidio de <65 años (95% CI 0.16–1.42; 60–550
exceso de muerte potencial EU)
de a 0.79% en la tasa de homicideios (0.06–1.52; 3–80 exceso de
muerte potencial EU).
 muertes de trafico en 1.39% (0.64–2.14; 290–980 menos
muertes potenciales [mean 630] EU-wide).
 No se detecta efecto de género en la relación
mortalidad- desempleo
 Hay una relación entre las muertes debidas a abuso
de alcohol en mujeres y el desempleo (χ.=5.41,
p=0.0194),
Stuckler D. The public health eff ect of economic crises and alternative policy
responses in Europe: an empirical analysis. Thelancet 2009; 379; 315-6

E. Baca-García
SUICIDIO DESEMPLEO
Stuckler D. The public health eff ect of economic crises and alternative policy
responses in Europe: an empirical analysis. Thelancet 2009; 379; 315-6

E. Baca-García
DURKHEIM
“An important question is to what extent today’s findings (ie, a change
in unemployment rates is followed by a change in suicide rates) are
consistent with findings from individual-level studies on the
association between unemployment and suicide (ie, individuals exposed
to unemployment are at increased risk of suicide).
Lundin A. Unemployment and suicide. Lancet 2013.
“The association between suicide and unemployment for 15-24 year old
males was comparatively high for the recent period, 1966-1990. The
increasingly youthful contribution to male suicide was demonstrated by
a rise in the loss of life years during 1973- 1984. Despite the inability
of any investigation based on aggregate data to establish an
unequivocable causal relationship”
Morrell S. Suicide and unemployment in australia 1907-1990. Soc. Sci. Med.
Vol.3 6,N o. 6.p p.7 49.-7561,9 93

E. Baca-García
DURKHEIM control depresión y alcohol
Fernquist RM. Archives of Suicide Research, 11:361–
Suicide rates (Belgium,Denmark,England=Wales, France,
Germany, Ireland, Italy, and theNetherlands) from 1973–1997

E. Baca-García
CRISIS Y SALUD MENTAL EN ESPAÑA
The mental health risks of economic crisis in Spain: evidence from primary care
centres, 2006 and 2010. European Journal of Public Health, 2013; 23 (1):103–108

E. Baca-García
SUICIDIO EN ESPAÑA 1981-2008
Alvaro-Meca A. Epidemiology of suicide in Spain, 1981e2008: A spatiotemporal
analysis. Public Health. http://dx.doi.org/10.1016/j.puhe.2012.12.007
“The spatiotemporal analysis for total suicide mortality. A clear
geographic pattern was found. The southern areas in Spain
(AndalucIa, Murcia, Extremadura) have the lowest gross domestic
product in Spain and have the highest suicide mortality rate.
Furthermore, Asturias and Galicia (rural areas) were had
increasing levels of suicide. The capitals of the provinces, including
Madrid, Barcelona, and Valencia (urban centres with high
population density), had high suicide rates. In contrast, Castilla
León, Castilla la Mancha and Aragón (unpopulated geographic
areas of Spain) had low suicide rate”

E. Baca-García
SUICIDIO EN ESPAÑA 1981-2008
Alvaro-Meca A. Epidemiology of suicide in Spain, 1981e2008: A spatiotemporal
analysis. Public Health. http://dx.doi.org/10.1016/j.puhe.2012.12.007
“The pattern of mortality was slightly different among men
compared with the total population. In this comparison, the only
areas with higher rates of suicide were Andalucia and Extremadura,
on one side, and Galicia and Asturias, on the other. No regional
trends were found among women”

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RISK FACTOR FOR SUICIDE
Hawton K, van Heeringen K. Suicide. Lancet. 2009 vol. 373 (9672): 1372-81

E. Baca-García
PROTECTORES
•RELIGIÓN
•SOPORTE SOCIAL
•EMBARAZO
•PRESENCIA DE
NIÑOS
BIOLÓGICOS
•HERENCIA
•MONOAMINAS
•LÍPIDOS
SOCIODEMO.
•HOMBRES
•EDADES
EXTREMAS
•DESVENTAJAS
SOCIALES
CLINICOS
•INTENTOS PREVIOS
•DEPRESIÓN
•PSICOSIS
•DROGAS
•PERSONALIDAD
EVENTOS
VITALES
•CONFILCTO
INTERPERSONAL
•MALTRATO
•AISLAMIENTO
PSICOLÓGICOS
•IMPULSIVIDAD
•AGRESIVIDAD
•DESESPERANZA
•ANHEDONIA
•REACTIVIDAD
EMOCIONAL
OTROS
•ACCESO A MEDIOS
LETALES
•CONTAGIO
•ENFERMEDAD
CRÓNICA
RIESGO Y PRONOSTICO CONDUCTA SUICIDA
Nock MK et al. Suicide and Suicidal Behavior. Epidemiol Rev 2008;30:133–154

E. Baca-García
WEIGHTING BIOLOGICAL AND CLINICAL FACTORS
Neuropsychophram 2001; Psychos Med 2003; JCP 2006; Stress and Health, 2007;
AM J Med Gen 2008; JCP 2008; AM J Med Gen 2010
0
5
10
15
20
25
30
35
Menses
Cholesterol
<160mg/dl
5-Ht2a
T1002C
5-HTPRL
HTR1E~GA
BRP~ACTN
2
Aggresivity
Impulsivity
ClusterB
Adult
physical
abuse
Interperson
alconcficts
Partner
conflicts
Theorical distribution
Blood donors
Psychiatric patients
OR BIOLOGICAL GENE PSYCHOLOGICAL-CLINICAL LIFE EXPERIENCE
Am J Psychiatry 2005; 162:1243–1252

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INTENTOS DE SUICIDIO vs SUICIDIO
Personality disorders and health problems distinguish attempters from
completers in a direct comparison, submitted.

E. Baca-García
Faltan estudios etiológicos para establecer la
relación entre situación económica y suicidio
Falacia ecológica: datos poblacionales no
son extrapolables a individuos
Depresión y alcholismo factores de confusión
para intepretar la relación entre suicidio y
situación económica
Factores de riesgo individuales
Coste individual, social y económico
CONCLUSIONES

E. Baca-García
EQUIPO
 Enrique Baca García
 Hilario Blasco Fontecilla
 Juan José Carballo Belloso
 Pablo Fernández Navarro
 Rebeca García Nieto
 Jorge López Castroman
 Concepción Vaquero
 Asesores y colaboradores
• Antonio Artés Rodríguez
• José de León
• María Oquendo
• Jerónimo Saiz Ruiz

E. Baca-García
Muchas gracias

E. Baca-García
PREDICTORES SUICIDIO TRAS HOSPITALIZACIÓN
Morrel S et al. Suicide and unemployment in Australia 1907-1990. Sm. Sri. Med. Vol.3
6,N o. 6.p p.7 49.-7561,9 93
While the aggregate data show that the
suicide/unemployment relationship is not a simple
year-by-year correlation, the present study strongly
supports the hypothesis that unemployment is significant
as a predisposing factor for increasing the risk
of suicide, especially in males
Female suicide rates were generally stable throughout the
period, whereas those for
males demonstrated sharp fluctuations with the peaks coinciding
with times of high unemployment.
The association between suicide and unemployment for 15524
year old males was comparatively high for
the recent period, 1966-1990. The increasingly youthful
contribution to male suicide was demonstrated
by a rise in the loss of life years during 1973- 1984. Despite the
inability of any investigation based on
aggregate data to establish an unequivocable causal
relationship, no evidence was detected to suggest that
relatively high population levels of unemployment were not
related to the occurrence of suicide.

E. Baca-García
MODELOS
This research examines empirically the determinants of suicides
inDenmarkover the period
1970–2006. To our knowledge, there exist no previous study that estimates
a dynamic
econometric model of suicides on the basis of time series data and
cointegration framework
at disaggregate level. Our results indicate that suicide is associated with a
range of
socio-economic factors but the strength of the association can differ by
gender. In particular,
we find that a rise in real per capita income and fertility rate decreases
suicides for
males and females. Divorce is positively associated with suicides and this
effect seems to
be stronger for men. A fall in unemployment rates seems to lower
significantly suicides
in males and females. Policy implications of suicides are discussed with
some appropriateAndrésa AR, Halicioglub F. Determinants of suicides in Denmark: Evidence from time
series data. Health Policy 98 (2010) 263–269
Bryan
Charnley

E. Baca-García
SUICIDIO DESEMPLEO
 Age-adjusted, gender-specific suicide trends for selected
 Western and Eastern
 Europe.countries in 1980–2008 were obtained from the World
 Health Organization (WHO) European Mortality Database,
 updated in January 2010 (http://data.euro.who.int/hfamdb).
 Several gaps in the WHO mortality data were filled using
 the Eurostat database (http://epp.eurostat.ec.europa.eu).
 Absolute numbers of employed people and population data
 for 1980–2008 were obtained from the Total Economy
 Database, developed by the Groningen Growth and Development
 Centre (http://www.conference-board.org)
 In line with Durkheim’s classic theory, work may be understood
 as one of the important ties that integrates individuals
 into the community and regulates their everyday life,
 providing them with realistic means of fulfilling some of
 their basic needs. Accordingly, merely having a position in
 the labour market would in itself appear very important
 (Wasserman and Mäkinen, 2009).
 Both the
 country level (represented by employment rates) and the
 individual level (represented by people’s attitudes towards
 employment problems) were considered. Overall, the
 results of the study generally support the hypothesis that
 suicidal behaviour is dependent to a certain extent on the
 situation on the labour market, and is characterized by an
 inverse relationship with employment in the majority of
 countries studied.
 It is worth bearing in mind that the
 Eastern European countries covered in the study underwent
 fundamental socioeconomic changes during the
 1990s, after the USSR collapsed. This transition period was
 accompanied by critical disruption of economic activity,
 resulting in high unemployment and marked labour-market
 insecurity. A rapid rise in suicide mortality was reported at
 the time (Mäkinen, 2000; Varnik et al., 2010).
 Suicidal behaviour is more strongly related to attitudes
Yur’yev A. Employment status influences suicide mortality in Europe. International
Journal of Social Psychiatry 2010; 58(1) 62–68

E. Baca-García
PREDICTORES SUICIDIO TRAS HOSPITALIZACIÓN
Troister T eta al. Review of Predictors of Suicide Within 1 Year of Discharge from a
Psychiatric Hospital. Current Psychiatry Reports 2008, 10:60–65
Conducta suicida OR
Intentos previos 3,1- 13,8
Ideación / intentos previa al ingreso 1,9- 3.4
Autolesiones/intentos durante le ingreso 2,6- 10,5
Atención sanitaria OR
Cumplimiento del tratamiento 8,0
Alta sin planificar 4,0
Continuidad de cuidado 16,8
We found that nearly half of suicide cases occurring within the
first month had taken place before their first out-patient
appointment.
Psychological Medicine (2009), 39, 443–449

E. Baca-García
Hampton T. Depression Care Effort Brings Dramatic Drop in Large HMO
Population’s Suicide Rate. JAMA, 2010; 103 (19): 1903-5
PREVENIR SIN PREDECIR
Redesign depression care delivery:
• Seguridad
• Efectividad: evitar infrautilizacion y
sobreutilización
• Centrado en el paciente: considerar sus
preferencias, necesidades y valores que
guían todas las decisiones
• Tiempo: Reducción de esperaas y retrasos
• Eficiente: evitar derroche
• Equidad

Enrique Baca. Crisis Económica y Suicidio

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